Mesothelioma Aid

Cooper, Hart, Leggiero & Whitehead

Breathlessness in advanced disease

Medicine
Volume 36, Issue 2, February 2008, Pages 82-87

Georgina Keenleysidea and Sam H. Ahmedzaia

Breathlessness is a distressing symptom which arises in many diseases
and has several pathophysiological causes, involving the interplay
between peripheral and central chemoreceptors, lung receptors, chest
wall and diaphragmatic muscles and cortical processing. Older people
and patients with cachexia
are more susceptible to breathlessness on exertion.

Most patients can be assessed with physical examination and simple
investigations including Hb, oxygen saturation, ECG and
imaging (X-ray and ultrasound). Research shows that opioid receptors
are important in the central medullary chemoreceptors but also in
the cortical areas. Thus, careful use of opioids can reduce the
sensation of breathlessness without compromising ventilatory control.
Benzodiazepines also reduce breathlessness, probably by their anxiolytic
and sedative actions. The combination of opioid and short-acting
benzodiazepine is especially useful. Nebulized furosemide is a new
approach which requires further research. Oxygen is indicated if
the saturation falls but increased airflow around the face, e.g.
with a fan, can also help. The combination of helium with oxygen
may be more effective than oxygen alone.

Non-invasive ventilation may be necessary in severe cases, e.g.
neuromuscular disease. Non-medical approaches, including breathing
training and relaxation, can help. Infusions of carefully titrated
opioid and midazolam can be used in the dying patient, together
with an anticholinergic if upper airways secretions are causing
‘death rattle’.